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Zhu B, Zhou R, Qin J, Li Y. Hierarchical Capability in Distinguishing Severities of Sepsis via Serum Lactate: A Network Meta-Analysis. Biomedicines 2024; 12:447. [PMID: 38398049 PMCID: PMC10886935 DOI: 10.3390/biomedicines12020447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Blood lactate is a potentially useful biomarker to predict the mortality and severity of sepsis. The purpose of this study is to systematically review the ability of lactate to predict hierarchical sepsis clinical outcomes and distinguish sepsis, severe sepsis and septic shock. Methods: We conducted an exhaustive search of the PubMed, Embase and Cochrane Library databases for studies published before 1 October 2022. Inclusion criteria mandated the presence of case-control, cohort studies and randomized controlled trials that established the association between before-treatment blood lactate levels and the mortality of individuals with sepsis, severe sepsis or septic shock. Data was analyzed using STATA Version 16.0. Results: A total of 127 studies, encompassing 107,445 patients, were ultimately incorporated into our analysis. Meta-analysis of blood lactate levels at varying thresholds revealed a statistically significant elevation in blood lactate levels predicting mortality (OR = 1.57, 95% CI 1.48-1.65, I2 = 92.8%, p < 0.00001). Blood lactate levels were significantly higher in non-survivors compared to survivors in sepsis patients (SMD = 0.77, 95% CI 0.74-0.79, I2 = 83.7%, p = 0.000). The prognostic utility of blood lactate in sepsis mortality was validated through hierarchical summary receiver operating characteristic curve (HSROC) analysis, yielding an area under the curve (AUC) of 0.72 (95% CI 0.68-0.76), accompanied by a summary sensitivity of 0.65 (95% CI 0.59-0.7) and a summary specificity of 0.7 (95% CI 0.64-0.75). Unfortunately, the network meta-analysis could not identify any significant differences in average blood lactate values' assessments among sepsis, severe sepsis and septic shock patients. Conclusions: This meta-analysis demonstrated that high-level blood lactate was associated with a higher risk of sepsis mortality. Lactate has a relatively accurate predictive ability for the mortality risk of sepsis. However, the network analysis found that the levels of blood lactate were not effective in distinguishing between patients with sepsis, severe sepsis and septic shock.
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Affiliation(s)
| | | | | | - Yifei Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, No. 20, 3rd Section, South Renmin Road, Chengdu 610041, China; (B.Z.); (R.Z.); (J.Q.)
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2
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Kim S, McGowan S, Brender T, Bamman D, Cobert J. "Fighting the Ventilator": Abandoning Exclusionary Violence Metaphors in the Intensive Care Unit. Ann Am Thorac Soc 2023; 20:1550-1553. [PMID: 37669463 PMCID: PMC10632934 DOI: 10.1513/annalsats.202306-562ip] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/05/2023] [Indexed: 09/07/2023] Open
Affiliation(s)
| | - Samuel McGowan
- Department of Internal Medicine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - David Bamman
- School of Information, University of California, Berkeley, Berkeley, California; and
| | - Julien Cobert
- Department of Anesthesiology, University of California, San Francisco, San Francisco, California
- Anesthesia Service, San Francisco Veterans Affairs Health Care System, San Francisco, California
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3
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Gomes CLR, Cleto-Yamane TL, Ruzani F, Suassuna JHR. Socioeconomic Influences on the Outcomes of Dialysis-Requiring Acute Kidney Injury in Brazil. Kidney Int Rep 2023; 8:1772-1783. [PMID: 37705894 PMCID: PMC10496017 DOI: 10.1016/j.ekir.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/03/2023] [Accepted: 06/05/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction Although research suggests that socioeconomic deprivation is linked to a higher incidence of acute kidney injury (AKI) and worse outcomes in high-income countries, there is limited knowledge about these epidemiologic factors in developing countries. In addition, the impact of medical institution administration (private versus public) on AKI outcomes remains to be determined. Methods We studied 15,186 pediatric and adult patients with dialysis-requiring AKI (AKI-D) admitted to private and public hospitals in Rio de Janeiro, Brazil. According to Brazil's demographic census, socioeconomic indicators were derived from patient zip codes. Propensity score matching analysis and a mixed-effect Cox regression were used to assess the impact of socioeconomic indicators and hospital governance on patient survival. Results Crude mortality rates were higher in private hospitals than in public hospitals (71.8% vs. 59.5%, P < 0.001) and were associated with significant differences in age (75 years, interquartile range [IQR]: 61-83 vs. 53 years, IQR: 31-66), baseline renal function (prevalence of chronic kidney disease [CKD]: 33.2% vs. 23%, P < 0.001), comorbidities (Charlson score: 2.03 ± 0.87 vs. 1.72 ± 0.75, P < 0.001), and severity of presentation (mechanical ventilation: 76.5% vs. 58% and vasopressors: 72.8% vs. 50.5%, P < 0.001). After adjustments and propensity score matching, we found no effect of different hospital administrations or socioeconomic factors on mortality. Baseline characteristics and the severity of presentation primarily influenced AKI-D prognosis. Conclusions Despite significant racial and socioeconomic differences in hospital governance, these indicators had no independent influence on mortality. Future epidemiologic studies should investigate these relevant assumptions to allow healthcare systems to manage this severe syndrome promptly.
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Affiliation(s)
- Conrado Lysandro Rodrigues Gomes
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Kidney Assistance Ltd., Rio de Janeiro, Brazil
| | - Thais Lyra Cleto-Yamane
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Frederico Ruzani
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Kidney Assistance Ltd., Rio de Janeiro, Brazil
| | - José Hermógenes Rocco Suassuna
- Clinical and Academic Unit of Nephrology, Hospital Universitário Pedro Ernesto, Faculty of Medical Sciences, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil
- Kidney Assistance Ltd., Rio de Janeiro, Brazil
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Angriman F, Lawler PR, Shah BR, Martin CM, Scales DC. Prevalent diabetes and long-term cardiovascular outcomes in adult sepsis survivors: a population-based cohort study. Crit Care 2023; 27:302. [PMID: 37525272 PMCID: PMC10391991 DOI: 10.1186/s13054-023-04586-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Sepsis survivors are at elevated risk for cardiovascular disease during long-term follow-up. Whether diabetes influences cardiovascular risk after sepsis survival remains unknown. We sought to describe the association of diabetes with long-term cardiovascular outcomes in adult sepsis survivors. METHODS Population-based cohort study in the province of Ontario, Canada (2008-2017). Adult survivors of a first sepsis-associated hospitalization, without pre-existing cardiovascular disease, were included. Main exposure was pre-existing diabetes (any type). The primary outcome was the composite of myocardial infarction, stroke, and cardiovascular death. Patients were followed up to 5 years from discharge date until outcome occurrence or end of study period (March 2018). We used propensity score matching (i.e., 1:1 to patients with sepsis but no pre-existing diabetes) to adjust for measured confounding at baseline. Cause-specific Cox proportional hazards models with robust standard errors were used to estimate hazard ratios (HR) alongside 95% confidence intervals (CI). A main secondary analysis evaluated the modification of the association between sepsis and cardiovascular disease by pre-existing diabetes. RESULTS 78,638 patients with pre-existing diabetes who had a sepsis-associated hospitalization were matched to patients hospitalized for sepsis but without diabetes. Mean age of patients was 71 years, and 55% were female. Median duration from diabetes diagnosis was 9.8 years; mean HbA1c was 7.1%. Adult sepsis survivors with pre-existing diabetes experienced a higher hazard of major cardiovascular disease (HR 1.25; 95% CI 1.22-1.29)-including myocardial infarction (HR 1.40; 95% CI 1.34-1.47) and stroke (HR 1.24; 95% CI 1.18-1.29)-during long-term follow-up compared to sepsis survivors without diabetes. Pre-existing diabetes modified the association between sepsis and cardiovascular disease (risk difference: 2.3%; 95% CI 2.0-2.6 and risk difference: 1.8%; 95% CI 1.6-2.0 for the effect of sepsis-compared to no sepsis-among patients with and without diabetes, respectively). CONCLUSIONS Sepsis survivors with pre-existing diabetes experience a higher long-term hazard of major cardiovascular events when compared to sepsis survivors without diabetes. Compared to patients without sepsis, the absolute risk increase of cardiovascular events after sepsis is higher in patients with diabetes (i.e., diabetes intensified the higher cardiovascular risk induced by sepsis).
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Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Patrick R Lawler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- McGill University Health Centre, Montreal, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Baiju R Shah
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Claudio M Martin
- Division of Critical Care, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
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5
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Phelps KB, Gebremariam A, Andrist E, Barbaro RP, Freed GL, Carlton EF. Children with severe sepsis: relationship between community level income and morbidity and mortality. Pediatr Res 2023:10.1038/s41390-023-02500-w. [PMID: 36804502 DOI: 10.1038/s41390-023-02500-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/05/2023] [Accepted: 01/13/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Health disparities surrounding pediatric severe sepsis outcomes remains unclear. We aimed to measure the relationship between indicators of socioeconomic status and mortality, hospital length of stay (LOS), and readmission rates among children hospitalized with severe sepsis. METHODS Children 0-18 years old, hospitalized with severe sepsis in the Nationwide Readmissions Database (2016-2018) were included. The primary exposure was median household income by ZIP Code of residence, divided into quartiles. RESULTS We identified 15,214 index pediatric severe sepsis hospitalizations. There was no difference in hospital mortality rate or readmission rate across income quartiles. Among survivors, patients in Q1 (lowest income) had a 2 day longer LOS compared to those in Q4 (Median 10 days [IQR 4-21] vs 8 days [IQR 4-18]; p < 0.0001). However, there was no difference after adjusting for multiple covariates. CONCLUSIONS Children living in Q1 had a 2 day longer LOS versus their peers in Q4. This was not significant on multivariable analysis, suggesting income quartile is not driving this difference. As pediatric severe sepsis remains an important source of morbidity and mortality in critically ill children, more sensitive metrics of socioeconomic status may better elucidate any disparities. IMPACT Children with severe sepsis living in the lowest income ZIP Codes may have longer hospital stays compared to peers in higher income communities. More precise metrics of socioeconomic status are needed to better understand health disparities in pediatric severe sepsis.
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Affiliation(s)
- Kayla B Phelps
- Divison of Pediatric Critical Care Medicine, Louisiana State University School of Medicine, New Orleans, LA, USA.
| | - Acham Gebremariam
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Erica Andrist
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Ryan P Barbaro
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Gary L Freed
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Division of General Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Erin F Carlton
- Susan B Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA
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Mariani J, Garau ML, Roitman AJ, Vukotich C, Perelis L, Ferrero F, Domínguez AG, Campos C, Serrano C, Villa Monte GG. Variability in Ethics Review for Multicenter Protocols in Buenos Aires, Argentina. An Observational Study. J Empir Res Hum Res Ethics 2023; 18:69-77. [PMID: 36285388 DOI: 10.1177/15562646221134620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
It has been reported that significant variability in the ethics review process affects multisite studies. We analyzed 1,305 applications for multicenter studies (409 unique protocols), from 1st January 2020 to 20th September 2021. We examined the variability in the times to approval and the first observation and the variation in the level of risk assigned. The median [IQR] variabilities were 42.19 [15.23-82.36] days and 8.00 [3.12-16.68] days, for the times to approval and to the first observation, respectively. There was disagreement in the level of risk assigned by the Research Ethics Committee (REC) in 24.0% of cases. Independent predictors of variability included the number of REC members. In our study, we found substantial variability in the ethics review process among health research protocols. Also, we describe methods to readily measure the delays and the variations in the ethics review process.
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Affiliation(s)
- Javier Mariani
- Coronary Unit Coordinator, Hospital de Alta Complejidad en Red "El Cruce", Buenos Aires, Argentina
| | - María Laura Garau
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Consejo de Investigación en Salud, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Adriel Jonas Roitman
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Comité de Ética en Investigación, Clínica y Maternidad Suizo Argentina, Ciudad Autónoma de Buenos Aires, Argentina
- Comité de Ética en Investigación Clínica Olivos, Buenos Aires, Argentina
- Comité de Ética en Investigación de la Dirección de Investigación para la Salud, Ministerio de Salud de la Nación, Ciudad Autónoma de Buenos Aires, Argentina
| | - Claudia Vukotich
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Instituto de Ciencias para la Familia, Universidad Austral, Buenos Aires, Argentina
- Comité de Ética en Investigación, Hospital General de Agudos E. Tornú, Argentina
| | - Leonardo Perelis
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Comité de Ética en Investigación, Hospital General de Agudos "José María Ramos Mejía", Ciudad Autónoma de Buenos Aires, Argentina
| | - Fernando Ferrero
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Departamento de Medicina, Hospital General de Niños "Pedro de Elizalde", Ciudad Autónoma de Buenos Aires, Argentina
| | - Adriana Gladys Domínguez
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Comité de Ética en Investigación del Hospital General de Agudos "Dr Abel Zubizarreta", Ciudad Autónoma de Buenos Aires, Argentina
- Comité de Ética en Investigación de la Dirección de Investigación para la Salud, Ministerio de Salud de la Nación, Ciudad Autónoma de Buenos Aires, Argentina
- Diplomatura de Ética en Investigación, Universidad Isalud, Ciudad Autónoma de Buenos Aires, Argentina
| | - Cecilia Campos
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Laboratory, Instituto de Tisioneumonología "Prof. Dr. Raúl Vaccarrezza", Argentina
- Facultad de Medicina, University of Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
| | - Cecilia Serrano
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Hospital "Dr Abel Zubizarreta", Ciudad Autónoma de Buenos Aires, Argentina
- Carrera Interdisciplinaria de Especialización en Neuropsicología Clínica, Facultad de Psicología, Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Neurología Cognitiva y Neuropsicología, Hospital "Dr Cesar Milstein", Ciudad Autónoma de Buenos Aires, Argentina
| | - Gabriel González Villa Monte
- Comité Central de Ética en Investigación, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
- Dirección General de Docencia, Investigación y Desarrollo Profesional, Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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Screening for Social Risk Factors in the ICU During the Pandemic. Crit Care Explor 2022; 4:e0761. [PMID: 36196435 PMCID: PMC9524932 DOI: 10.1097/cce.0000000000000761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
UNLABELLED Due to limitations in data collected through electronic health records, the social risk factors (SRFs) that predate severe illness and restrict access to critical care services are poorly understood. OBJECTIVES This study explored the feasibility and utility of directly eliciting SRFs in the ICU by implementing a screening program. DESIGN SETTING AND PARTICIPANTS Five hundred sixty-six critically ill patients at the medical ICU of Robert Wood Johnson University Hospital from July 1, 2019, to September 31, 2021, were interviewed for SRFs using an adapted version of the American Academy of Family Physicians' Social Needs Screening Tool. MAIN OUTCOMES AND MEASURES For each SRFs, we compared basic demographic factors, proxies of socioeconomic status, and severity score between those with and without the SRFs through chi-square tests and Wilcoxon rank-sum tests. Furthermore, we determined the prevalence of SRFs overall, before, and during the COVID-19 pandemic. RESULTS Of critically ill patients, 39.58% reported at least one SRF. Age, zip-code matched median household income, and insurance type differed depending on the SRFs. Notably, patients with SRFs were admitted with a lower average severity score, indicating reduced risk in mortality. Since March 2020, the prevalence of SRFs in the ICU overall fell from 54.47% to 35.44%. Conversely, the proportion of patients unable to afford healthcare increased statistically significantly from 7.32% to 18.06%. CONCLUSIONS AND RELEVANCE Screening for SRFs in the ICU detected the presence of disproportionally low-risk patients whose access to critical care services became restricted throughout the pandemic.
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Ledesma M, Todero MF, Maceira L, Prieto M, Vay C, Galas M, López B, Yokobori N, Rearte B. Peptidome profiling for the immunological stratification in sepsis: a proof of concept study. Sci Rep 2022; 12:11469. [PMID: 35794460 PMCID: PMC9259554 DOI: 10.1038/s41598-022-15792-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 06/29/2022] [Indexed: 11/09/2022] Open
Abstract
Sepsis has been called the graveyard of pharmaceutical companies due to the numerous failed clinical trials. The lack of tools to monitor the immunological status in sepsis constrains the development of therapies. Here, we evaluated a test based on whole plasma peptidome acquired by MALDI-TOF-mass spectrometer and machine-learning algorithms to discriminate two lipopolysaccharide-(LPS) induced murine models emulating the pro- and anti-inflammatory/immunosuppression environments that can be found during sepsis. The LPS group was inoculated with a single high dose of LPS and the IS group was subjected to increasing doses of LPS, to induce proinflammatory and anti-inflammatory/immunosuppression profiles respectively. The LPS group showed leukopenia and higher levels of cytokines and tissue damage markers, and the IS group showed neutrophilia, lymphopenia and decreased humoral response. Principal component analysis of the plasma peptidomes formed discrete clusters that mostly coincided with the experimental groups. In addition, machine-learning algorithms discriminated the different experimental groups with a sensitivity of 95.7% and specificity of 90.9%. Data reveal the potential of plasma fingerprints analysis by MALDI-TOF-mass spectrometry as a simple, speedy and readily transferrable method for sepsis patient stratification that would contribute to therapeutic decision-making based on their immunological status.
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Affiliation(s)
- Martín Ledesma
- Laboratorio de Bacteriología, Departamento de Bioquímica Clínica, Hospital de Clínicas "José de San Martín", Facultad de Farmacia y Bioquímica, UBA, Av. Córdoba 2351, C1120, CABA, Argentina.,Consejo Nacional de Investigaciones Científicas Y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB, CABA, Argentina
| | - María Florencia Todero
- Instituto de Medicina Experimental (IMEX) - CONICET - Academia Nacional de Medicina, Pacheco de Melo 3081, C1425AUM, CABA, Argentina
| | - Lautaro Maceira
- Instituto de Medicina Experimental (IMEX) - CONICET - Academia Nacional de Medicina, Pacheco de Melo 3081, C1425AUM, CABA, Argentina
| | - Mónica Prieto
- Servicio de Bacteriología Especial. Instituto Nacional de Enfermedades Infecciosas (INEI), ANLIS "Dr. C. G. Malbrán", Av. Vélez Sarsfield 563, C1282AFF, CABA, Argentina
| | - Carlos Vay
- Laboratorio de Bacteriología, Departamento de Bioquímica Clínica, Hospital de Clínicas "José de San Martín", Facultad de Farmacia y Bioquímica, UBA, Av. Córdoba 2351, C1120, CABA, Argentina
| | - Marcelo Galas
- Special Program of AMR, Communicable Diseases and Environmental Determinants of Health Department, Pan-American Health Organization, 525 23rd St NW, Washington, DC, 20037, USA
| | - Beatriz López
- Departamento de Bacteriología. INEI, ANLIS "Dr. C. G. Malbrán", Av. Vélez Sarsfield 563, C1282AFF, CABA, Argentina
| | - Noemí Yokobori
- Servicio de Micobacterias INEI, ANLIS "Dr. C. G. Malbrán", Av. Vélez Sarsfield 563, C1282AFF, CABA, Argentina.,Consejo Nacional de Investigaciones Científicas Y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB, CABA, Argentina
| | - Bárbara Rearte
- Instituto de Medicina Experimental (IMEX) - CONICET - Academia Nacional de Medicina, Pacheco de Melo 3081, C1425AUM, CABA, Argentina. .,Consejo Nacional de Investigaciones Científicas Y Técnicas (CONICET), Godoy Cruz 2290, C1425FQB, CABA, Argentina.
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9
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Plotnikow GA, Gogniat E, Accoce M, Navarro E, Dorado JH. Epidemiology of mechanical ventilation in Argentina. The EpVAr multicenter observational study. Med Intensiva 2022; 46:372-382. [PMID: 35660286 DOI: 10.1016/j.medine.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/22/2021] [Accepted: 10/04/2021] [Indexed: 06/15/2023]
Abstract
OBJETIVE To describe mechanical ventilation (MV) practices in Argentina, and to explore factors associated with ICU mortality in this population. DESIGN A prospective, multicenter, observational study was carried out. SETTING Intensive Care. PATIENTS We enrolled patients above 18 years old admitted to any of the participating ICUs requiring invasive MV for at least 12 h since the admission to the healthcare institution, including MV initiation in emergency department, operating room or other hospitals. INTERVENTIONS None. VARIABLES All variables were classified into three categories: variables related to demographic and clinical factors before the MV, factors related to the first day on MV, and factors related to events happening during the MV (complications and weaning from MV). Mechanical ventilation weaning and mortality were classified according to WIND. RESULTS The primary analysis included 950 patients. The main indication for MV was acute respiratory failure (58% of patients). Initial ventilation mode was volume control-continuous mandatory ventilation in 75% of cases. ICU and hospital mortality were 44.6% and 47.9% respectively. The variables identified as independent predictors of mortality in ICU were age (OR 3.48 IC 95% 1.22-11.66; p = 0.028), failure to implement NIV before MV (OR 2.76 IC 95% 1.02-7.10; p = 0.038), diagnosis of sepsis (OR 2.46 IC 95% 1.09-5.47; p = 0.027) and extubation failure (OR 4.50 IC 95% 2.05-9.90; p < 0.001). CONCLUSIONS The present study allowed us to describe the characteristics and clinical course of the patients who received mechanical ventilation in Argentina, finding as the main result that mortality was higher than that reported in international studies.
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Affiliation(s)
- G A Plotnikow
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Hospital Británico de Buenos Aires, CABA, Argentina; Docente Adjunto de Cátedra de Kinesfisiatría Cardiorrespiratoria de la Carrera de Kinesiología y Fisiatría, Universidad Abierta Interamericana, CABA, Argentina; Director del Grupo de Estudios Especializados en VM, Universidad Abierta Interamericana, CABA, Argentina.
| | - E Gogniat
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina
| | - M Accoce
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Docente Adjunto de Cátedra de Kinesfisiatría Cardiorrespiratoria de la Carrera de Kinesiología y Fisiatría, Universidad Abierta Interamericana, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina
| | - E Navarro
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina; Centro del Parque, CABA, Argentina
| | - J H Dorado
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, CABA, Argentina; Sanatorio Anchorena San Martín, Buenos Aires, Argentina
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10
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Detelich JF, Kyaw NT, Judd SE, Bennett A, Wang HE, Kramer MR, Waller LA, Martin GS, Kempker JA. Home-to-Hospital Distance and Outcomes Among Community-Acquired Sepsis Hospitalizations. Ann Epidemiol 2022; 72:26-31. [PMID: 35551996 PMCID: PMC9629891 DOI: 10.1016/j.annepidem.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/31/2022] [Accepted: 05/02/2022] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the hypothesis that longer distance from home-to-hospital is associated with worse outcomes among hospitalizations for community-acquired sepsis. METHODS A secondary analysis of data from the REasons for Geographic and Racial Differences in Stroke (REGARDS) prospective cohort of 30,239 white and black US adults ≥ 45 years old was conducted. Self-reported hospitalizations for serious infection between 2003-2012 fulfilling 2/4 systemic inflammatory response syndrome criteria were included. Estimated driving distance was derived from geocoded data and evaluated continuously and as quartiles of very close, close, far, very far (<3.1, 3.1-5.8, 5.9-11.5, and >11.5 miles respectively). The primary outcome was 30-day mortality while the secondary outcome was sequential organ failure assessment (SOFA) score on arrival. RESULTS 912 hospitalizations for community-acquired sepsis had adequate data for analysis. The median (interquartile range) estimated driving distance was 5.8 miles (3.1,11.7), and 54 (5.9%) experienced the primary outcome. Compared to living very close, participants living very far had a mortality odds ratio of 1.30 (95% CI 0.64,2.62) and presenting SOFA score difference of 0.33 (95% CI -0.03,0.68). CONCLUSIONS Among a national sample of community-acquired sepsis hospitalizations, there was no significant association between home-to-hospital distance and either 30-day mortality or SOFA score on hospital presentation.
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Affiliation(s)
- Joshua F Detelich
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA.
| | - Nang Thu Kyaw
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA
| | - Suzanne E Judd
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Aleena Bennett
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL
| | - Henry E Wang
- Department of Emergency Medicine, The Ohio State University, Columbus, OH
| | - Michael R Kramer
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Lance A Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Greg S Martin
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jordan A Kempker
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA
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11
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Plotnikow G, Gogniat E, Accoce M, Navarro E, Dorado J. Epidemiología de la ventilación mecánica en Argentina. Estudio observacional multicéntrico EpVAr. Med Intensiva 2021. [DOI: 10.1016/j.medin.2021.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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12
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Siu JYM. Health inequality experienced by the socially disadvantaged populations during the outbreak of COVID-19 in Hong Kong: An interaction with social inequality. HEALTH & SOCIAL CARE IN THE COMMUNITY 2021; 29:1522-1529. [PMID: 33125773 DOI: 10.1111/hsc.13214] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 09/23/2020] [Accepted: 10/09/2020] [Indexed: 06/11/2023]
Abstract
Health inequality creates conditions for the transmission of infectious diseases, and existing health disparities can contribute to unequal burdens of morbidity and mortality. In Hong Kong, low socioeconomic districts were the epicentres of third-wave outbreak of COVID-19 in July and August 2020, suggesting that people from low socioeconomic class are vulnerable groups. Socially disadvantaged people are relatively more vulnerable to the physical, mental, and social impacts of infectious diseases. To achieve more effective infection control, the social determinants of health and existing health inequalities should be identified, and understanding the experiences of socially disadvantaged groups in the COVID-19 outbreak will be beneficial to health authorities in formulating a responsive infection control policy targeting the needs of the socially disadvantaged. This article investigates the experiences of economically disadvantaged groups during the COVID-19 outbreak and examines how they were further disadvantaged in the outbreak by delineating how health inequality intersected with social inequality. In-depth, semistructured interviews were conducted from February to April 2020 with 35 participants from the poverty class in Hong Kong. The high prices of surgical face masks and disinfecting products as well as the economic impacts induced by COVID-19-related social distancing policies imposed severe economic burden on the participants. In addition to economic and housing deprivation, social inequality was closely associated with health inequality, which made the participants more vulnerable to infection. Social inequality is associated with and can worsen health inequality. Here, the participants, who were of low socioeconomic status were more disadvantaged in health and in the attainment of social resources such as employment, education, face masks, disinfection products and right to use public facilities, during the COVID-19 outbreak. All these elements may have interrelated effects and in turn limit accessibility to healthcare and lead to less positive health outcomes and consequently to health inequality.
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Affiliation(s)
- Judy Yuen-Man Siu
- Department of Applied Social Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, Hong Kong
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13
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Estenssoro E, Loudet CI, Ríos FG, Kanoore Edul VS, Plotnikow G, Andrian M, Romero I, Piezny D, Bezzi M, Mandich V, Groer C, Torres S, Orlandi C, Rubatto Birri PN, Valenti MF, Cunto E, Sáenz MG, Tiribelli N, Aphalo V, Reina R, Dubin A. Clinical characteristics and outcomes of invasively ventilated patients with COVID-19 in Argentina (SATICOVID): a prospective, multicentre cohort study. THE LANCET RESPIRATORY MEDICINE 2021; 9:989-998. [PMID: 34224674 PMCID: PMC8253540 DOI: 10.1016/s2213-2600(21)00229-0] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Although COVID-19 has greatly affected many low-income and middle-income countries, detailed information about patients admitted to the intensive care unit (ICU) is still scarce. Our aim was to examine ventilation characteristics and outcomes in invasively ventilated patients with COVID-19 in Argentina, an upper middle-income country. METHODS In this prospective, multicentre cohort study (SATICOVID), we enrolled patients aged 18 years or older with RT-PCR-confirmed COVID-19 who were on invasive mechanical ventilation and admitted to one of 63 ICUs in Argentina. Patient demographics and clinical, laboratory, and general management variables were collected on day 1 (ICU admission); physiological respiratory and ventilation variables were collected on days 1, 3, and 7. The primary outcome was all-cause in-hospital mortality. All patients were followed until death in hospital or hospital discharge, whichever occurred first. Secondary outcomes were ICU mortality, identification of independent predictors of mortality, duration of invasive mechanical ventilation, and patterns of change in physiological respiratory and mechanical ventilation variables. The study is registered with ClinicalTrials.gov, NCT04611269, and is complete. FINDINGS Between March 20, 2020, and Oct 31, 2020, we enrolled 1909 invasively ventilated patients with COVID-19, with a median age of 62 years [IQR 52-70]. 1294 (67·8%) were men, hypertension and obesity were the main comorbidities, and 939 (49·2%) patients required vasopressors. Lung-protective ventilation was widely used and median duration of ventilation was 13 days (IQR 7-22). Median tidal volume was 6·1 mL/kg predicted bodyweight (IQR 6·0-7·0) on day 1, and the value increased significantly up to day 7; positive end-expiratory pressure was 10 cm H2O (8-12) on day 1, with a slight but significant decrease to day 7. Ratio of partial pressure of arterial oxygen (PaO2) to fractional inspired oxygen (FiO2) was 160 (IQR 111-218), respiratory system compliance 36 mL/cm H2O (29-44), driving pressure 12 cm H2O (10-14), and FiO2 0·60 (0·45-0·80) on day 1. Acute respiratory distress syndrome developed in 1672 (87·6%) of patients; 1176 (61·6%) received prone positioning. In-hospital mortality was 57·7% (1101/1909 patients) and ICU mortality was 57·0% (1088/1909 patients); 462 (43·8%) patients died of refractory hypoxaemia, frequently overlapping with septic shock (n=174). Cox regression identified age (hazard ratio 1·02 [95% CI 1·01-1·03]), Charlson score (1·16 [1·11-1·23]), endotracheal intubation outside of the ICU (ie, before ICU admission; 1·37 [1·10-1·71]), vasopressor use on day 1 (1·29 [1·07-1·55]), D-dimer concentration (1·02 [1·01-1·03]), PaO2/FiO2 on day 1 (0·998 [0·997-0·999]), arterial pH on day 1 (1·01 [1·00-1·01]), driving pressure on day 1 (1·05 [1·03-1·08]), acute kidney injury (1·66 [1·36-2·03]), and month of admission (1·10 [1·03-1·18]) as independent predictors of mortality. INTERPRETATION In patients with COVID-19 who required invasive mechanical ventilation, lung-protective ventilation was widely used but mortality was high. Predictors of mortality in our study broadly agreed with those identified in studies of invasively ventilated patients in high-income countries. The sustained burden of COVID-19 on scarce health-care personnel might have contributed to high mortality over the course of our study in Argentina. These data might help to identify points for improvement in the management of patients in middle-income countries and elsewhere. FUNDING None. TRANSLATION For the Spanish translation of the Summary see Supplementary Materials section.
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Affiliation(s)
- Elisa Estenssoro
- Hospital Interzonal de Agudos General San Martín, Buenos Aires, Argentina.
| | - Cecilia I Loudet
- Hospital Interzonal de Agudos General San Martín, Buenos Aires, Argentina
| | | | | | | | | | | | | | - Marco Bezzi
- Hospital Santojanni, Buenos Aires, Argentina
| | | | - Carla Groer
- Hospital Juan A Fernández, Buenos Aires, Argentina
| | | | | | | | | | | | - María G Sáenz
- Hospital Interzonal de Agudos General San Martín, Buenos Aires, Argentina
| | - Norberto Tiribelli
- Complejo Médico de la Policía Federal Argentina Churruca Visca, Buenos Aires, Argentina
| | | | - Rosa Reina
- Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
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Wang GS, You KM, Jo YH, Lee HJ, Shin JH, Jung YS, Hwang JE. Association of Health Insurance Status with Outcomes of Sepsis in Adult Patients: A Retrospective Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115777. [PMID: 34072210 PMCID: PMC8198413 DOI: 10.3390/ijerph18115777] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/26/2021] [Accepted: 05/27/2021] [Indexed: 11/16/2022]
Abstract
(1) Background: Sepsis is a life-threatening disease, and various demographic and socioeconomic factors affect outcomes in sepsis. However, little is known regarding the potential association between health insurance status and outcomes of sepsis in Korea. We evaluated the association of health insurance and clinical outcomes in patients with sepsis. (2) Methods: Prospective cohort data of adult patients with sepsis and septic shock from March 2016 to December 2018 in three hospitals were retrospectively analyzed. We categorized patients into two groups according to their health insurance status: National Health Insurance (NHI) and Medical Aid (MA). The primary end point was in-hospital mortality. The multivariate logistic regression model and propensity score matching were used. (3) Results: Of a total of 2526 eligible patients, 2329 (92.2%) were covered by NHI, and 197 (7.8%) were covered by MA. The MA group had fewer males, more chronic kidney disease, more multiple sources of infection, and more patients with initial lactate > 2 mmol/L. In-hospital, 28-day, and 90-day mortality were not significantly different between the two groups and in-hospital mortality was not different in the subgroup analysis. Furthermore, health insurance status was not independently associated with in-hospital mortality in multivariate analysis and was not associated with survival outcomes in the propensity score-matched cohort. (4) Conclusions: Our propensity score-matched cohort analysis demonstrated that there was no significant difference in in-hospital mortality by health insurance status in patients with sepsis.
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Affiliation(s)
- Gaon-Sorae Wang
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Korea; (G.-S.W.); (Y.-S.J.)
| | - Kyoung-Min You
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University, Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea; (H.-J.L.); (J.-H.S.)
- Correspondence: (K.-M.Y.); (Y.-H.J.); Tel.: +82-10-8525-4298 (K.-M.Y.); +82-10-4579-7255 (Y.-H.J.)
| | - You-Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea;
- Department of Emergency Medicine, Seoul National University College of Medicine, 103, Daehak-ro, Jongno-gu, Seoul 03080, Korea
- Correspondence: (K.-M.Y.); (Y.-H.J.); Tel.: +82-10-8525-4298 (K.-M.Y.); +82-10-4579-7255 (Y.-H.J.)
| | - Hui-Jai Lee
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University, Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea; (H.-J.L.); (J.-H.S.)
| | - Jong-Hwan Shin
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University, Boramae Medical Center, 20, Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea; (H.-J.L.); (J.-H.S.)
- Department of Emergency Medicine, Seoul National University College of Medicine, 103, Daehak-ro, Jongno-gu, Seoul 03080, Korea
| | - Yoon-Sun Jung
- Department of Emergency Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Korea; (G.-S.W.); (Y.-S.J.)
| | - Ji-Eun Hwang
- Department of Emergency Medicine, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam 13620, Korea;
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15
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Garay OU, Guiñazú G, Cornistein W, Farina J, Valentini R, Levy Hara G. Budget impact analysis of using procalcitonin to optimize antimicrobial treatment for patients with suspected sepsis in the intensive care unit and hospitalized lower respiratory tract infections in Argentina. PLoS One 2021; 16:e0250711. [PMID: 33930050 PMCID: PMC8087000 DOI: 10.1371/journal.pone.0250711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Inappropriate antibiotic use represents a major global threat. Sepsis and bacterial lower respiratory tract infections (LRTIs) have been linked to antimicrobial resistance, carrying important consequences for patients and health systems. Procalcitonin-guided algorithms may represent helpful tools to reduce antibiotic overuse but the financial burden is unclear. The aim of this study was to estimate the healthcare and budget impact in Argentina of using procalcitonin-guided algorithms to guide antibiotic prescription. METHODS A decision tree was used to model health and cost outcomes for the Argentinean health system, over a one-year duration. Patients with suspected sepsis in the intensive care unit and hospitalized patients with LRTI were included. Model parameters were obtained from a focused, non-systematic, local and international bibliographic search, and validated by a panel of local experts. Deterministic and probabilistic sensitivity analyses were performed to analyze the uncertainty of parameters. RESULTS The model predicted that using procalcitonin-guided algorithms would result in 734.5 [95% confidence interval (CI): 1,105.2;438.8] thousand fewer antibiotic treatment days, 7.9 [95% CI: 18.5;8.5] thousand antibiotic-resistant cases avoided, and 5.1 [95% CI: 6.7;4.2] thousand fewer Clostridioides difficile cases. In total, this would save $422.4 US dollars (USD) [95% CI: $935;$267] per patient per year, meaning cost savings of $83.0 [95% CI: $183.6;$57.7] million USD for the entire health system and $0.4 [95% CI: $0.9;$0.3] million USD for a healthcare provider with 1,000 cases per year of sepsis and LRTI patients. The sensitivity analysis showed that the probability of cost-saving for the sepsis patient group was lower than for the LRTI patient group (85% vs. 100%). CONCLUSIONS Healthcare and financial benefits can be obtained by implementing procalcitonin-guided algorithms in Argentina. Although we found results to be robust on an aggregate level, some caution must be used when focusing only on sepsis patients in the intensive care unit.
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Affiliation(s)
- Osvaldo Ulises Garay
- Market Access and Medical Affairs, Roche Diagnostics, Buenos Aires, Argentina
- * E-mail:
| | - Gonzalo Guiñazú
- Ricardo Gutiérrez Children’s Hospital, Buenos Aires, Argentina
| | | | - Javier Farina
- Hospital Cuenca Alta Néstor Kirchner, Buenos Aires, Argentina
| | | | - Gabriel Levy Hara
- Unit of Infectious Diseases, Hospital Carlos G Durand, Buenos Aires, Argentina
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Gu M, Mei XL, Zhao YN. Sepsis and Cerebral Dysfunction: BBB Damage, Neuroinflammation, Oxidative Stress, Apoptosis and Autophagy as Key Mediators and the Potential Therapeutic Approaches. Neurotox Res 2020; 39:489-503. [PMID: 32876918 DOI: 10.1007/s12640-020-00270-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 02/07/2023]
Abstract
Sepsis-associated cerebral dysfunction is complex pathophysiology, generated from primary infections that are developed elsewhere in the body. The neonates, elderly population and chronically ill and long-term hospitalized patients are predominantly vulnerable to sepsis and related cerebral damage. Generally, electrophysiological recordings, severity and sedation scales, computerized imaging and spectroscopy techniques are used for its detection and diagnosis. About the underlying mechanisms, enhanced blood-brain barrier permeability and metalloprotease activity, tight junction protein loss and endothelial cell degeneration promote the influx of inflammatory and toxic mediators into the brain, triggering cerebrovascular damage. An altered neutrophil count and phenotype further dysregulate the normal neuroimmune responses and neuroendocrine stability via modulated activation of protein kinase C-delta, nuclear factor kappa-B and sphingolipid signaling. Glial activation, together with pro-inflammatory cytokines and chemokines and the Toll-like receptor, destabilize the immune system. Moreover, superoxides and hydroperoxides generate oxidative stress and perturb mitochondrial dynamics and ATP synthesis, propagating neuronal injury cycle. Activated mitochondrial apoptotic pathway, characterized by increased caspase-3 and caspase-9 cleavage and Bax/Bcl2 ratio in the hippocampal and cortical neurons, stimulate neurocognitive impairments. Additionally, altered LC3-II/I and P62/SQSTM1, p-mTOR, p-AMPK1 and p-ULK1 levels and dysregulated autophagosome-lysosome fusion decrease neuronal and glial energy homeostasis. The therapies and procedures for attenuating sepsis-induced brain damage include early resuscitation, cerebral blood flow autoregulation, implantable electric vagus nerve stimulation, antioxidants, statins, glucocorticoids, neuroimmune axis modulators and PKCδ inhibitors. The current review enumerates the pathophysiology of sepsis-induced brain damage, its diagnosis, the role of critical inducers and mediators and, ultimately, therapeutic measures attenuating cerebrovascular degeneration.
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Affiliation(s)
- Ming Gu
- Department of Emergency and Critical Care Medicine, The Second Hospital of Jilin University, Changchun, China
| | - Xiang-Lin Mei
- Department of Pathology, The Second Hospital of Jilin University, Changchun, China
| | - Ya-Nan Zhao
- Neurology Department, China-Japan Union Hospital of Jilin University, Changchun, 130000, People's Republic of China.
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17
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Dubin A, Loudet C, Kanoore Edul VS, Osatnik J, Ríos F, Vásquez D, Pozo M, Lattanzio B, Pálizas F, Klein F, Piezny D, Rubatto Birri PN, Tuhay G, García A, Santamaría A, Zakalik G, González C, Estenssoro E. Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina. Ann Intensive Care 2020; 10:40. [PMID: 32297028 PMCID: PMC7158970 DOI: 10.1186/s13613-020-00659-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Resuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. Our aim was to characterize cardiovascular and fluid management of sepsis in Argentina, a low and middle-income country (LMIC). Furthermore, we sought to test whether the utilization of dynamic tests of fluid responsiveness, as a guide for fluid therapy after initial resuscitation in patients with persistent or recurrent hypoperfusion, was associated with decreased mortality. METHODS Secondary analysis of a national, multicenter prospective cohort study (n = 787) fulfilling Sepsis-3 definitions. Epidemiological characteristics, hemodynamic management data, type of fluids and vasopressors administered, physiological variables denoting hypoperfusion, use of tests of fluid responsiveness, and outcomes, were registered. Independent predictors of mortality were identified with logistic regression analysis. RESULTS Initially, 584 of 787 patients (74%) had mean arterial pressure (MAP) < 65 mm Hg and/or signs of hypoperfusion and received 30 mL/kg of fluids, mostly normal saline (53%) and Ringer lactate (35%). Vasopressors and/or inotropes were administered in 514 (65%) patients, mainly norepinephrine (100%) and dobutamine (9%); in 22%, vasopressors were administered before ending the fluid load. After this, 413 patients (53%) presented persisting or recurrent hypotension and/or hypoperfusion, which prompted administration of additional fluid, based on: lactate levels (66%), urine output (62%), heart rate (54%), central venous O2 saturation (39%), central venous-arterial PCO2 difference (38%), MAP (31%), dynamic tests of fluid responsiveness (30%), capillary-refill time (28%), mottling (26%), central venous pressure (24%), cardiac index (13%) and/or pulmonary wedge pressure (3%). Independent predictors of mortality were SOFA and Charlson scores, lactate, requirement of mechanical ventilation, and utilization of dynamic tests of fluid responsiveness. CONCLUSIONS In this prospective observational study assessing the characteristics of resuscitation of septic patients in Argentina, a LMIC, the prevalent use of initial fluid bolus with normal saline and Ringer lactate and the use of norepinephrine as the most frequent vasopressor, reflect current worldwide practices. After initial resuscitation with 30 mL/kg of fluids and vasopressors, 413 patients developed persistent or recurrent hypoperfusion, which required further volume expansion. In this setting, the assessment of fluid responsiveness with dynamic tests to guide fluid resuscitation was independently associated with decreased mortality.
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Affiliation(s)
- Arnaldo Dubin
- Servicio de Terapia Intensiva, Sanatorio Otamendi, Azcuénaga 870, C1115 AAB, Buenos Aires, Argentina.
| | - Cecilia Loudet
- Hospital Interzonal de Agudos San Martin de La Plata, La Plata, Buenos Aires, Argentina
| | | | | | - Fernando Ríos
- Hospital Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | | | - Mario Pozo
- Clínica Bazterrica, Buenos Aires, Argentina
| | | | | | - Francisco Klein
- Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | - Damián Piezny
- Hospital Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | - Paolo N Rubatto Birri
- Servicio de Terapia Intensiva, Sanatorio Otamendi, Azcuénaga 870, C1115 AAB, Buenos Aires, Argentina
| | - Graciela Tuhay
- Hospital Universitario Fundación Favaloro, Buenos Aires, Argentina
| | | | | | | | | | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, La Plata, Buenos Aires, Argentina
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